Middle Cerebral Artery Aneurysm: Complex Wide-Necked and Lobulated Aneurysm of the Middle Cerebral Artery Bifurcation, Treated by Stent-Assisted Coil Occlusion Using a pCONUS2 Aneurysm Bridging Device and p48mw Flow Modulation Device Deployed Through the pCONUS2 Device; Two Treatment Sessions, Complete Aneurysm Occlusion, and Good Clinical Outcome
A 72-year-old female patient was admitted to another hospital due to an upper respiratory tract infection. While carrying out a non-contrast-enhanced cranial CT (NCCT) to investigate recurrent headaches and dizziness, a hyperdense Sylvian lesion was incidentally found on the right-hand side. An MRI examination was then performed, which revealed a lobulated wide-necked saccular aneurysm located on the bifurcation of the right-hand middle cerebral artery (MCA). The aneurysm neck was close to the origins of both efferent M2 branches.
During the first endovascular treatment session, we were able to completely reconstruct the aneurysmal neck by implanting a pCONUS2 device into the aneurysm sac. This device is crowned with six petals, which prevented any coil loops from protruding into the parent vessel of the wide-necked aneurysm during coil occlusion. The attempt to electively coil the secondary lobule of the aneurysm failed due to the coils repeatedly compacting in the main aneurysmal sac. During a second treatment session, two p48 flow modulation devices were telescopically deployed from the inferior trunk of the MCA through to the M1 segment, crossing the pCONUS2 stent. Both procedures were well tolerated, and the patient’s postoperative neurological condition remained unchanged from baseline. This combined treatment strategy, which involved implanting both a pCONUS2 bifurcation stent and a low-profile flow modulation device in order to treat a complex middle cerebral artery aneurysm, is the main topic of this chapter.
KeywordsMiddle cerebral artery Stent-assisted coil occlusion pCONUS2 bifurcation stent Flow diversion p48 flow modulation device pCONUS2/p48 combination
- Bhogal P, Bleise C, Chudyk J, Lylyk I, Viso R, Perez N, Henkes H, Lylyk P. The p48mw flow diverter – initial human experience. Clin Neuroradiol. 2019; https://doi.org/10.1007/s00062-019-00827-8.
- De Leacy RA, Fargen KM, Mascitelli JR, Fifi J, Turkheimer L, Zhang X, Patel AB, Koch MJ, Pandey AS, Wilkinson DA, Griauzde J, James RF, Fortuny EM, Cruz A, Boulos A, Nourollah-Zadeh E, Paul A, Sauvageau E, Hanel R, Aguilar-Salinas P, Novakovic RL, Welch BG, Almardawi R, Jindal G, Shownkeen H, Levy EI, Siddiqui AH, Mocco J. Wide-neck bifurcation aneurysms of the middle cerebral artery and basilar apex treated by endovascular techniques: a multicentre, core lab adjudicated study evaluating safety and durability of occlusion (BRANCH). J Neurointerv Surg. 2019;11(1):31–6. https://doi.org/10.1136/neurintsurg-2018-013771.CrossRefPubMedGoogle Scholar
- Schneiders JJ, Marquering HA, van den Berg R, VanBavel E, Velthuis B, Rinkel GJ, Majoie CB. Rupture-associated changes of cerebral aneurysm geometry: high-resolution 3D imaging before and after rupture. AJNR Am J Neuroradiol. 2014;35(7):1358–62. https://doi.org/10.3174/ajnr.A386.CrossRefPubMedGoogle Scholar